CWR AUD INTAKE FORM Logo

  • CAROLINA WELLNESS & RECOVERY

    INTAKE PAPERWORK

  • CONSENT TO TREAT

  • General Patient Consent for Care Form/General Consent to Care:

     

    I hereby consent to medical care and treatment, as ordered by a provider, while such medical care and treatment is provided through Carolina Wellness and Recovery on an outpatient/ office visit basis. This consent includes my consent for all medical services rendered under the general or specific instructions of a provider; including treatment by a mid-level provider (Nurse Practitioner or Physician Assistant), and other health care providers or the designees under the direction of a physician, as deemed reasonable and necessary. I agree and acknowledge that Carolina Wellness and Recovery is not liable for the actions or omissions of, or the instructions given by the physicians/providers who treat me while I am a patient. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatments.

     

    Telemedicine: I understand that telemedicine (defined as the use of medical information exchanged from one site to another via electronic communications for the health of the patient, including consultative, diagnostic, and treatment services) may be employed to facilitate my medical care. All electronic transmission of data will be restricted to authorized recipients in compliance with the Federal Health Insurance Portability and Accountability Act (HIPPA) and applicable state privacy laws.

     

    To the Patient: You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. By signing below, you are indicating that:

    (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and

    (2) you consent to treatment at this office or any other satellite office. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

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  • ASSIGNMENT OF BENEFITS

  • FINANCIAL RESPONSIBILITY:

    All professional services rendered are charged to the patient and due at the time of service unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments. I understand that I am responsible for turning over payments and EOBs from my insurance carrier for services rendered by Carolina Wellness & Recovery (CWR) within 7 days of receipt or be subject to finance charges and the cost of the collection process.

    ASSIGNMENT OF BENEFITS:

    I hereby assign all medical and counseling services to which I am entitled. I hereby authorize and direct my insurance carrier(s) to issues payment check(s) directly to CWR for services rendered to me regardless of my insurance benefits, if any. I understand that I am responsible for any and all amounts not covered by insurance. I furthermore understand that I am waiving any anti-assignment clauses that are written into my health care contract. I have requested that the office of CWR be the agent for filing, processing, and appealing of claims related specifically to treatment rendered by this office. I understand that I have the opportunity to submit my bills directly to my health insurance carrier but have chosen voluntarily to have the claims submitted by and paid directly to the office of CWR with the accompanying explanation of benefits.

    AUTHORIZATION TO RELEASE INFORMATION:

    I hereby authorize CWR to (1) release any information necessary to insurance carriers regarding my treatments (2) process insurance claims generated in the course of treatment, and (3) allow a photocopy of my signature to be used to process insurance claims for the period of a lifetime. This order will remain in effect until revoked by me in writing.

    I have requested services from CWR on behalf of myself, and understand that by making this request, I become fully financially responsible for any and all charges incurred during the course of the treatment.

    I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

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  • We understand the following sections are lengthy, and completing forms can be time-consuming. However, the details you provide are essential for us to deliver personalized care that meets your specific needs. Please take a few minutes to fully read and complete the following:

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  • MEDICAL HISTORY

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  • CONSENT TO RELEASE / RECEIVE CONFIDENTIAL INFORMATION

  • I authorize Carolina Wellness & Recovery to:

  • *IF YOU WOULD LIKE CAROLINA WELLNESS & RECOVERY TO BE ABLE TO DISCUSS/DISCLOSE YOUR TREATMENT INFORMATION, LABWORK, DIAGNOSES, BILLING INFORMATION, ETC. WITH AN INDIVIDUAL OTHER THAN YOURSELF, THEY MUST BE LISTED BELOW:

  • INSURANCE

  • I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken in reliance on it. This consent will last while I am being treated for opioid dependence by the physician specified unless the physician specified above is otherwise notified by me.

    I understand that the records to be released may contain information pertaining to psychiatric treatment and / or treatment for alcohol and / or drug dependency. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient.

    I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information / records under 42 CFR Part 2, and I further acknowledge that understand those rights.

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  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

  • By signing below, I am acknowledging that:

    • I am either the patient or the patient's personal representative;
    • I have received a copy of the "Notice of Privacy Practices" for Carolina Wellness & Recovery; and 
    • I understand that I may contact the person named in the Notice if I have questions about the content of the Notice.

    *Full copy of Notice of Privacy Practices is available at the bottom of this page

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    • Click to expand Notice of Privacy Practices: 

    • NOTICE OF PRIVACY PRACTICES:

      As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

      This notice describes how health information about you (as a patient of this practice) may be used and disclosed and how you can get access to your individually identifiable health information.

      Please review this notice carefully.

      A. Our commitment to your privacy:
      Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

      We realize that these laws are complicated, but we must provide you with the following important information:

      • How we may use and disclose your PHI,
      • Your privacy rights in your PHI,
      • Our obligations concerning the use and disclosure of your PHI.

      The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

      B. If you have questions about this Notice, please contact:

      Jennifer Miles, Program Director, Carolina Wellness and Recovery, (864) 887-6190

      C. We may use and disclose your PHI in the following ways:

      The following categories describe the different ways in which we may use and disclose your PHI.

      1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.

      2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

      3. Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations.

      4. Optional Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment if you consent for us to do so.

      5. Optional Release of information to family/friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you only if you opt to do so by signed consent and specify to whom and what information may be shared.

      6. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

      D. Use and disclosure of your PHI in certain special circumstances:

      The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

      1. Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:


      • Maintaining vital records, such as births and deaths,
      • Reporting child abuse or neglect,
      • Preventing or controlling disease, injury or disability,
      • Notifying a person regarding potential exposure to a communicable disease,
      • Notifying a person regarding a potential risk for spreading or contracting a disease or condition,
      • Reporting reactions to drugs or problems with products or devices,
      • Notifying individuals if a product or device they may be using has been recalled,
      • Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information,


      2. Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

      3. Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

      4. Law enforcement. We may release PHI if asked to do so by a law enforcement official:

      • Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement,
      • Concerning a death we believe has resulted from criminal conduct,
      • Regarding criminal conduct at our offices,
      • In response to a warrant, summons, court order, subpoena or similar legal process,
      • To identify/locate a suspect, material witness, fugitive or missing person,
      • In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

      5. Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

      6. Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

      7. National security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations.

      8. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

      9. Workers’ compensation. Our practice may release your PHI for workers’ compensation and similar programs.

      E. Your rights regarding your PHI:

      You have the following rights regarding the PHI that we maintain about you:

      1. Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Carolina Wellness and Recovery specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

      2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Carolina Wellness and Recovery. Your request must describe in a clear and concise fashion:

      • The information you wish restricted,
      • Whether you are requesting to limit our practice’s use, disclosure or both,
      • To whom you want the limits to apply.

      3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Carolina Wellness and Recovery in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

      4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Carolina Wellness and Recovery. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

      5. Accounting of disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented – for example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Jennifer Miles at Carolina Wellness and Recovery at 864-887-6190. All requests for an “accounting of disclosures” must state a time period.

      6. Right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact any staff member at Carolina Wellness and Recovery.

      7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Jennifer Miles, Program Director at Carolina Wellness and Recovery. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

      8. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note: we are required to retain records of your care.

      Again, if you have any questions regarding this notice or our health information privacy policies, please contact Jennifer Miles, Program Director and Carolina Wellness and Recovery, LLC.

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